Mental Health Disorders: Saunders NCLEX Exam Questions with 100% Correct Answers

Aclient says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?" Correct Answer 3 Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. A client diagnosed with delirium becomes disor- iented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room. Correct Answer 2 Rationale: Provision ofaconsistentdailyroutineand alowstim- ulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses'station may become necessary but is not the initial action. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will pro- vide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate Correct Answer 4 Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or plea- sure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.